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CASE REPORT
Year : 2023 | Volume
: 17
| Issue : 1 | Page : 97-100
A successful pregnancy and delivery after heart transplantation: The first case report in Saudi Arabia
Abdullah AlRaffa, Samahir AlJubairy, Sara J Alwatban
Department of Anesthesiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Correspondence Address:
Samahir AlJubairy
Department of Anesthesiology, King Faisal Specialist Hospital and Research Center, Almather, Makka Almukarama Road 11564 Riyadh
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sja.sja_523_22
| Date of Submission | 13-Jul-2022 |
| Date of Decision | 02-Aug-2022 |
| Date of Acceptance | 14-Oct-2022 |
| Date of Web Publication | 02-Jan-2023 |
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Pregnancy following heart transplant (HT) surgery poses a high risk to the patient, and limited data are available on practices for post-HT pregnant patients. We report a case of a 34-year-old female patient in her 20th week of pregnancy, diagnosed with restrictive cardiomyopathy at 20 years of age. An HT procedure was performed 5 years ago on the patient. The patient had multiple miscarriages and in-vitro fertilization in 2021. The patient presented in the 20th week of gestation with shortness of breath and delivered prematurely via cesarean section. The procedure was successfully performed under spinal anesthesia with no complications, and the patient was stable. Implementing a multidisciplinary team in managing such challenging cases would further improve anesthesia management in the future.
Keywords: Heart transplant (HT), high-risk pregnancy, immunosuppression, miscarriages, preeclampsia
How to cite this article:
AlRaffa A, AlJubairy S, Alwatban SJ. A successful pregnancy and delivery after heart transplantation: The first case report in Saudi Arabia. Saudi J Anaesth 2023;17:97-100 |
How to cite this URL:
AlRaffa A, AlJubairy S, Alwatban SJ. A successful pregnancy and delivery after heart transplantation: The first case report in Saudi Arabia. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:97-100. Available from: https://www.saudija.org/text.asp?2023/17/1/97/364867 |
| Introduction | |  |
Pregnancy after heart transplantation (HT) has increased since its first report in 1988.[1],[2] The number of patients with HTs has increased due to the rising success of HT cases in adults and the survival of pediatric cardiac transplant recipients. However, no case of successful neonatal delivery by HT recipients has been reported in Saudi Arabia. Concerns regarding the mothers' longevity and the overall risk to the mother and fetus during pregnancy have been raised.[2],[3] The American Transplantation Society Consensus Conference on Reproductive Issues recommends prenatal counseling before pregnancy, which must be followed during the post-conception period.[4]
| Case Report | | |
A 34-year-old patient with Gravida 3 Parity 0 + 2 presented to the clinic in her 20th week of gestation. The patient had two recurrent pregnancy losses at five and eight weeks of gestational age. In May 2021, the patient decided to undergo in-vitro fertilization. The cardiology team was on board with the conception plan. The patient followed up with the obstetrician/gynecologist (OB/GYN) and cardiac clinic throughout her pregnancy. At 25 weeks of gestation, the patient began to have high blood sugar readings, and the endocrine team was consulted. The ultrasound of fetal growth and the well-being results were normal. According to the endocrine team's recommendations, the patient started on insulin and lifestyle modification.
At the age of 22, the patient was diagnosed with restrictive cardiomyopathy. The patient was referred with a history of shortness of breath by another hospital. An echocardiogram revealed restrictive cardiomyopathy. Subsequently, the patient was hospitalized for further evaluation. The results indicated restrictive cardiomyopathy/hypertrophic cardiomyopathy with a restrictive pattern, normal left ventricular systolic function, and confirmed right heart catheterization with a hemodynamic study.
A biopsy in 2009 exhibited mild interstitial fibrosis with no evidence of amyloidosis. Afterward, the patient's condition deteriorated at the age of 30. In 2014, the patient was diagnosed with atrial fibrillation and liver cirrhosis with intact synthetic liver function secondary to cardiac disease and was frequently admitted to the hospital. On November 30, 2017, the patient received an HT. Since then, the patient has received treatment consisting of tacrolimus, mycophenolate, azathioprine, multiple vitamins, heparin, diltiazem, and prednisolone and has remained stable.
During the pregnancy, a multidisciplinary (OB/GYN physician, obstetric anesthesia team, cardiology team, and neonatal intensive care unit [NICU] team) meeting was arranged to determine the time and mode of delivery. The decision was made to deliver the baby at 34 weeks with an elective cesarean section. In the 32nd week, the patient had premature labor signs and high blood pressure readings (150–160/100–90 mmHg). An emergency cesarean section was performed.
In January 2022, the patient was taken to the operative room and attached to monitors from the American Society of Anesthesia (five-lead electrocardiogram, O2 saturation, and noninvasive blood pressure cuff). An awake arterial line and two extensive intravenous lines were inserted. Emergency, induction, and inotrope medications were prepared, and spinal anesthesia with intrathecal morphine and fentanyl was used. Fluid started at a rate of 80 mL/h as coloading, and norepinephrine infusion started at 0.05 mcg/kg/min to support the hemodynamics for the sympathectomy [See Appendix]. A wedge was placed, and the surgery started. The baby was delivered, and the neonatal outcome was male with a birth weight of 1810 g and an Apgar score of 7–8–9. The baby was admitted to the NICU.
The patient received carbetocin (uterotonic) medication with caution, and the patient's uterus responded very well. The norepinephrine was titrated until weaned. The patient received adjuvant medication (ondansetron, ketorolac, and acetaminophen) and a total fluid of 1.5 L of ringer lactate. At the end of the operation, the patient had an estimated blood loss of 600 mL and a urine output of 400 mL (clear/light yellow). Finally, the patient was shifted to a high-dependency-unit bed for post-operative monitoring and was conscious, oriented, and pain-free. The patient reached full recovery with no complications. In addition, the patient was discharged 5 days after delivery. A follow-up echocardiogram was performed, which indicated no abnormalities. Patient consent was obtained for this study.
| Discussion | | |
The International Society of Heart and Lung Transplantation Guidelines for the care of HT recipients recommended that a multidisciplinary team, including experts in various fields, such as fetal medicine, cardiology, and transplant medicine, is often needed to provide the best possible care for pregnant HT recipients.[5] The recipients should refrain from attempting pregnancy within 1 year after an HT. However, a baseline assessment of the liver and kidney function is usually required for pregnant HT recipients. Monitoring blood pressure and blood sugar is essential. Pregnant HT recipients risk developing preeclampsia and gestational diabetes as well.[5],[6]
In addition, a recent meta-analysis of 385 pregnancies in 272 cardiothoracic transplant recipients included 220 pregnancies in 140 HT patients. The mean transplant-to-pregnancy interval was 81.4 months for HT recipients with an average maternal age of 28 years.[7] Concerning delivery modes, vaginal delivery was reported to be well endured by HT patients induced at or near term. Cesarean delivery should be reserved for the usual obstetrical indications.[4] However, in one review, the cesarean delivery rate among cardiac transplantation patients was 33% higher than in a control group (23%), despite the recommendation.[8]
| Conclusion | | |
Recommendations for the overall management of pregnancy in the post-HT recipient are scarce in the literature. The optimal timing and management of pregnancy in post-HT patients is challenging and should be coordinated by a multidisciplinary team of healthcare providers. This case is the first successful parturition by an HT recipient in Saudi Arabia. The successful outcome of this case can be credited to the involvement of a multidisciplinary team and good cooperation from the patient.
Ethical approval
This research case report has been approved by the research advisory council and the ethical committee at King Faisal Specialist Hospital and Research Center (PUB#2225176).
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Löwenstein BR, Vain NW, Perrone SV, Wright DR, Boullón FJ, Favaloro R. Successful pregnancy and vaginal delivery after heart transplantation. Am J Obstet Gynecol 1988;158:589-90.  |
| 2. | Coscia LA, Constantinescu S, Moritz MJ, Frank AM, Ramirez CB, Maley WR, et al. Report from the National Transplantation Pregnancy Registry (NTPR): Outcomes of pregnancy after transplantation. Clin Transpl 2010:65-85. |
| 3. | Troché V, Ville Y, Fernandez H. Pregnancy after heart or heart-lung transplantation: A series of 10 pregnancies. Br J Obstet Gynaecol 1998;105:454-8. |
| 4. | McKay DB, Josephson MA, Armenti VT, August P, Coscia LA, Davis CL, et al.; Women's Health Committee of the American Society of Transplantation. Reproduction and transplantation: Report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5:1592-9. |
| 5. | Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al.; International Society of Heart and Lung Transplantation Guidelines. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010;29:914-56. |
| 6. | Abdalla M, Mancini DM. Management of pregnancy in the post-cardiac transplant patient. Semin Perinatol 2014;38:318-25. |
| 7. | Acuna S, Zaffar N, Dong S, Ross H, D'Souza R. Pregnancy outcomes in women with cardiothoracic transplants: A systematic review and meta-analysis. J Heart Lung Transplant 2020;39:93-102. |
| 8. | Wagoner LE, Taylor DO, Olsen SL, Price GD Sr, Rasmussen LG, Larsen CB, et al. Immunosuppressive therapy, management, and outcome of heart transplant recipients during pregnancy. J Heart Lung Transplant 1993;12:993-9. |
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